Why Did the Best Prepared Country in the World Fare So Poorly during COVID?

Jennifer B. Nuzzo and Jorge R. Ledesma

Journal of Economic Perspectives—Volume 37, Number 4—Fall 2023

This study reviews what we think we know about the US experience during COVID-19 and where the data point toward identifying the source of America’s profound and deadly failures, to improve preparedness and response to the next pandemic.

However, without a full audit of the inner workings of the US governmental response, we are left with holes in understanding how one of the best-prepared countries in the world suffered worse from the pandemic than its peers.

SUMMARY

The Global Health Security Index in 2021 ranked the United States as the country best prepared in the world for a pandemic.

Today, it is an unquestioned fact that the United States was unprepared for COVID-19. That was the reality faced across the country and across society. The U.S., which accounts for less than five percent of the world’s population, accounts for more than 15 percent of the officially reported COVID deaths, upwards of 6.5 million as of May 2023.

Why Did the Best Prepared Country in the World Fare So Poorly?

• Collectively, the existing literature suggests that the United States mounted a response that failed to make full use of the preparedness capacities it had, was hampered by politics, made poor use of data, and neglected to overcome intrinsic social vulnerabilities that helped the virus spread and caused high mortality.

The Exceptional Toll of COVID-19 in the U.S.

• The number of deaths related to the pandemic in 2020 and 2021 was so large U.S. life expectancy dropped for those two consecutive years, reaching a low not seen since the mid-1990s and a two-year decline that was the biggest since 1921-23.
• Understanding why the U.S. reported the greatest number of COVID-19 deaths requires more careful analysis than simply comparing reported case and death numbers.
  • Inadequacies in global surveillance drove misperception that the best prepared countries suffered the worst outcomes.
  • Trying to track cases across countries may only be measuring how much or how well countries are counting.

• Better to use metrics less dependent on the extent of testing, such as ‘excess deaths’ which can quantify the total mortality impact of the pandemic.
  • Measures of excess deaths suggest that many countries with lower reported COVID-19 cases may have suffered more greatly than their official statistics indicated.

The U.S. stands out as a clear outlier: although among the highest prepared, it experienced the third-highest aged-adjusted mortality – more than eight times higher than what would have been expected.

Gaps and Challenges for U.S. Preparedness

• Specific gaps in U.S. pandemic preparedness may have proven especially harmful during COVID, along with a failure to use resources appropriately in response.
  • Existing risks or missing capacities in one area could hinder use of other capacities.
• Deficiencies in U.S. health care system hinder preparedness and response.
  • U.S. ranked 38^th out of 60 high-income countries in number of physicians per capita
  • U.S. ranked 40^th for number of hospital beds per capita
  • U.S. ranked 175^th in the world for access to health care due to lack of universal health coverage and high out-of-pocket health care costs.
• Existing preparedness capacities not as functional as previously thought
  • State cuts in public health spending translated to cuts of more than 55,000 jobs in local health departments
  • U.S. has high percentage of its population in congregate settings, such as nursing homes, as compared to other countries.

The Potential Disconnect Between Preparedness and Response

• Preparedness, encompassing the tools that are amassed and the actions taken prior to an emergency, represents only the first half of the equation. The second part entails response – what countries actually do during a health emergency.

• How governments, organizations, and individuals will use their capacities and overcome risk factors will ultimately determine the number of lives that will be saved or lost.

• The United States did not fully make use of its preparedness capacities in its response to the COVID-19 pandemic. A key initial lapse was its failure to quickly make use of its massive network of high-quality laboratories to diagnose and characterize infections.
  • Being slow to establish testing relative to other high-preparedness countries, allowed the virus to spread silently in communities, making it difficult to slow or contain the spread.
  • Even after testing was established throughout the United States, delays in getting those test results to patients persisted throughout much of the pandemic.
• Politics seemed to play an important role in the pattern of COVID-19 mortality. Though public support for the health agencies’ handling of the pandemic was initially high among members of both political parties, overall support eroded over time, with greater declines seen among Republicans.
  • This partisan erosion of support for health agencies’ response tracked with partisan lack of compliance with public health recommendations aimed at slowing the spread of the virus. An association developed between politics and poor health outcomes.
  • Understanding the interactions of which came first—loss of public support for the COVID-19 response or loss of some political leaders’ interest in responding to COVID-19—is important to know. If it is the former, developing and socializing better pandemic response playbooks could be necessary. If it is the latter, better equipping politicians and public health officials to lead during health emergencies may be helpful.
  •  Inconsistent messaging from public health leaders may have also played a role. Improved communication messaging – clear, science-based communication --is critical for future public health emergencies.

• The U.S. struggled to aggregate, analyze, and publish real-time COVID-19 data to help state and local governments, businesses, schools, community groups, and individuals make decisions about how best to protect themselves.
  • The lack of adequate data likely undermined the U.S. ability to mount responses tailored to local circumstances.
  • For example, while debates were raging about whether school closures were affecting disease transmission rate, the U.S. government did not have a national databased on school closures.
• The U.S. was late to increase genetic testing needed to track variants of COVID, which likely hindered its response to deadlier and more transmissible variants.
• The U.S. did not respond in ways that would counterbalance underlying social vulnerabilities likely to increase COVID-19 tolls.
  • Disparities in stark racial/ethnic composition of reported COVID-19 cases, hospitalizations, and deaths, pointed to a need to increase efforts to protect those at greatest risk.

The Need for Consensus on Lessons for Future Health Emergencies

Without a full audit of the inner workings of the US governmental response, we are left with holes in understanding how one of the best-prepared countries in the world suffered worse from the pandemic than its peers.

• These conclusions are only suggestive. The academic literature and public media accounting of the US experience do not tell us about the decision- making, resource constraints, and operational tradeoffs that government leaders experienced.
• Ideally, the US government would pass legislation to create a serious bipartisan audit of its COVID experience—one that opens the books on efforts of the Biden, Trump, and earlier Administrations to prepare for and respond to pandemic threats.
• Much like the passage of a law requiring an inquiry into US missteps leading up to 9/11 (Commission on Terrorist Attacks upon the United States 2004), a thorough record and investigation of governmental efforts to prepare for pandemic threats are needed to understand what the United States did and did not do, and why the country failed to make better use of its prepandemic advantages.